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Dunlap E, Conway R, Conway L, Fox C, Nagarsheth K. Percutaneous Aortoiliac Thromboendarterectomy for Acute Limb Ischemia. Vasc Endovascular Surg 2024; 58:523-529. [PMID: 38148675 DOI: 10.1177/15385744231183492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Aortoiliac occlusive disease (AIOD) can occur from either chronic, progressive atherosclerotic disease, acute on chronic thrombosis or acute arterial embolism, and can all result in limb ischemia. Bypass surgery had long been the gold standard for treatment for AIOD, however, with advances in endovascular techniques, minimally invasive treatment of aortoiliac lesions has become the first line choice of management in many cases. Herein, we describe a case of utilizing the Inari ClotTriever to perform aortoiliac mechanical thrombectomy and the ARTIX thrombectomy system to perform an embolectomy the superficial femoral artery, highlighting new therapies to treat AIOD.
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Affiliation(s)
- Eleanor Dunlap
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Robert Conway
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Lauren Conway
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Charles Fox
- University of Maryland Medical Center, Baltimore, MD, USA
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2
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Mol BM, Verwer MC, Fijnheer R, Florie J, Groot OA, Hietbrink F, Nijkeuter M, Vonken EJPA, van Weel V, de Kleijn DPV, de Borst GJ. Predictors of bleeding complications during catHeter-dirEcted thrombolysis for peripheral arterial occlusions (POCHET). PLoS One 2024; 19:e0302830. [PMID: 38722842 PMCID: PMC11081216 DOI: 10.1371/journal.pone.0302830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/13/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION The risk of major bleeding complications in catheter directed thrombolysis (CDT) for acute limb ischemia (ALI) remains high, with reported major bleeding complication rates in up to 1 in every 10 treated patients. Fibrinogen was the only predictive marker used for bleeding complications in CDT, despite the lack of high quality evidence to support this. Therefore, recent international guidelines recommend against the use of fibrinogen during CDT. However, no alternative biomarkers exist to effectively predict CDT-related bleeding complications. The aim of the POCHET biobank is to prospectively assess the rate and etiology of bleeding complications during CDT and to provide a biobank of blood samples to investigate potential novel biomarkers to predict bleeding complications during CDT. METHODS The POCHET biobank is a multicentre prospective biobank. After informed consent, all consecutive patients with lower extremity ALI eligible for CDT are included. All patients are treated according to a predefined standard operating procedure which is aligned in all participating centres. Baseline and follow-up data are collected. Prior to CDT and subsequently every six hours, venous blood samples are obtained and stored in the biobank for future analyses. The primary outcome is the occurrence of non-access related major bleeding complications, which is assessed by an independent adjudication committee. Secondary outcomes are non-major bleeding complications and other CDT related complications. Proposed biomarkers to be investigated include fibrinogen, to end the debate on its usefulness, anti-plasmin and D-Dimer. DISCUSSION AND CONCLUSION The POCHET biobank provides contemporary data and outcomes of patients during CDT for ALI, coupled with their blood samples taken prior and during CDT. Thereby, the POCHET biobank is a real world monitor on biomarkers during CDT, supporting a broad spectrum of future research for the identification of patients at high risk for bleeding complications during CDT and to identify new biomarkers to enhance safety in CDT treatment.
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Affiliation(s)
- Barend M. Mol
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten C. Verwer
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob Fijnheer
- Department of Hematology, Meander Medical Center, Amersfoort, The Netherlands
| | - Jasper Florie
- Department of Interventional Radiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Oscar A. Groot
- Intensive Care Department, Meander Medical Center, Amersfoort, The Netherlands
| | - Falco Hietbrink
- Department Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evert-Jan P. A. Vonken
- Department of Interventional Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vincent van Weel
- Department of Vascular Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Zenunaj G, Baldazzi G, Acciarri P, Gasbarro V, Cosacco AM, Serra R, Traina L. Treatment of true superficial femoral artery aneurysms: the 15-year experience of a single centre. Ann R Coll Surg Engl 2024; 106:425-431. [PMID: 37983018 PMCID: PMC11060849 DOI: 10.1308/rcsann.2023.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/21/2023] Open
Abstract
OBJECTIVE True superficial femoral artery aneurysms (SFAAs) are rare and traditionally treated by open repair. However, the endovascular approach excluding the aneurysm sac with a covered stent may be an alternative. This study aimed to compare the outcomes of the open and endovascular repair of SFAAs. METHODS This is a retrospective, observational, monocentric study. The main endpoints were: technical success, limb salvage and primary patency rate, and hospitalisation time. RESULTS We identified 49 SFAAs in 40 patients; the mean age was 73.3±10.1 years, the mean diameter of SFAAs was 5.41±3.64cm, and 61.2% were symptomatic for ischaemic or compression-related signs. The indication for open repair was given mainly for complex SFAAs involving the distal third of the superficial femoral artery and with an ipsilateral popliteal aneurysm. Among the 36 open-repair patients, 33 underwent ligation and revascularisation via bypass or graft interposition, and 3 patients underwent simple ligation without revascularisation. The endovascular approach was adopted mainly for aneurysms located in the medial third of the SFAA, which underwent covered stenting in 12 patients and coil embolisation in 1 patient. The technical success was 100% in all cases. There were no statistical differences in terms of primary patency and limb salvage rate between groups at two and four years. The mean hospitalisation time was 10±4 and 3±1 days after open and endovascular treatment, respectively. CONCLUSIONS The endovascular approach may be a valid alternative for isolating SFAAs offering good results and shorter hospitalisation. Open repair remains a valid approach, particularly in complex aneurysms.
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Affiliation(s)
- G Zenunaj
- University Hospital of Ferrara, Italy
| | | | | | | | | | - R Serra
- Università Magna Graecia di Catanzaro, Italy
| | - L Traina
- University Hospital of Ferrara, Italy
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Korosoglou G, Torsello G, Saratzis A, Isernia G, Kontopodis N, González TM, Jacobs K, Van Herzeele I, Zayed H, Stavroulakis K. Editor's Choice - Endovascular Versus Surgical Treatment for All Comer Patients With Prosthetic Bypass Graft Occlusion: The Multicentre ENSUPRO Study. Eur J Vasc Endovasc Surg 2024; 67:786-796. [PMID: 37543355 DOI: 10.1016/j.ejvs.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 06/10/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Bypass surgery plays a key role in complex lower limb lesions. However, there is a lack of evidence regarding the management of symptomatic prosthetic bypass graft (PBG) occlusion. This study aimed to report outcomes following open, hybrid, or endovascular management of patients presenting with symptomatic PBG occlusion. METHODS A multicentre, retrospective cohort study was conducted, including patients presenting with PBG occlusion between January 2014 and December 2021 from 18 centres. It assessed the comparative value of treatment strategies, including (1) recanalisation of native vessels, (2) endovascular treatment of the failed PBG, (3) hybrid treatment, and (4) open surgery. The primary outcome measure was amputation free survival (AFS, time to major amputation and or death), whereas all cause mortality, major amputation, PBG re-occlusion, target lesion revascularisation (TLR), and Rutherford category (RC) improvement during follow up were considered as secondary endpoints. RESULTS Of 260 patients with occluded PBGs, 108 (41.5%) were treated endovascularly (24 [22.2%] by recanalisation of native vessels and 84 [77.7%] by PBG re-opening), 57 (21.9%) underwent hybrid revascularisation, and 58 (22.3%) had surgery. In addition, 27 (10.4%) were treated conservatively and 10 (3.8%) received systemic thrombolysis. With a median follow up of 1.4 (0.6 - 3.0) years, AFS was 95.5%, 76.4%, 45.5%, and 37.1%, respectively in Groups 1 - 4 (p = .007). Older age and non-endovascular treatment (HR 1.05 and 1.70; p < .01 for both) were independent predictors of poor AFS. Endovascular treatment was associated with lower rates of major amputation (p = .04), PBG re-occlusion (p < .001), and TLR (p = .037), and higher RC improvements (p < .001), whereas all cause mortality was comparable between treatment groups (p = .21). CONCLUSION Endovascular treatment is associated with higher rates of AFS and RC improvement and lower rates of PBG re-occlusion and TLR in patients with PBG occlusion.
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Affiliation(s)
| | - Giovanni Torsello
- University Hospital Münster, Institute for Vascular Research, Franziskus Hospital, Münster, Germany
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Giacomo Isernia
- Department of Vascular and Endovascular Surgery, University Hospital of Perugia, Perugia, Italy
| | | | | | - Karen Jacobs
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Pelletier J, Koyfman A, Long B. Acute aortic occlusion: A narrative review for emergency clinicians. Am J Emerg Med 2024; 79:192-197. [PMID: 38460466 DOI: 10.1016/j.ajem.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/11/2024] Open
Abstract
INTRODUCTION Acute aortic occlusion (AAO) is a rare but serious condition associated with significant morbidity and mortality. OBJECTIVE This review provides an emergency medicine focused evaluation of AAO, including presentation, assessment, and emergency department (ED) management based on current evidence. DISCUSSION AAO refers to obstruction of blood flow through the aorta due to either thrombosis or embolism. This condition primarily affects older adults ages 60-70 with cardiovascular comorbidities and most commonly presents with signs and symptoms of acute limb ischemia, though the gastrointestinal tract, kidneys, and spinal cord may be affected. The first line imaging modality includes computed tomography angiography of the chest, abdomen, and pelvis. ED resuscitative management consists of avoiding extremes of blood pressure or heart rate, maintaining normal oxygen saturation and euvolemic status, anticoagulation with heparin, and pain control. Emergent consultation with the vascular surgery specialist is recommended to establish a plan for restoration of perfusion to ischemic tissues via endovascular or open techniques. High rates of baseline comorbidities present in the affected population as well as ischemic and reperfusion injuries place AAO patients at high risk for complications in an immediate and delayed fashion after surgical management. CONCLUSIONS An understanding of AAO can assist emergency clinicians in diagnosing and managing this rare but devastating disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Jarosinski M, Kennedy JN, Khamzina Y, Alie-Cusson FS, Tzeng E, Eslami M, Sridharan ND, Reitz KM. Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy. J Vasc Surg 2024; 79:1151-1162.e3. [PMID: 38224861 PMCID: PMC11032234 DOI: 10.1016/j.jvs.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/23/2023] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND Acute limb ischemia (ALI) carries a 15% to 20% risk of combined death or amputation at 30 days and 50% to 60% at 1 year. Percutaneous mechanical thrombectomy (PT) is an emerging minimally invasive alternative to open thrombectomy (OT). However, ALI thrombectomy cases are omitted from most quality databases, limiting comparisons of limb and survival outcomes between PT and OT. Therefore, our aim was to compare in-hospital outcomes between PT and OT using the National Inpatient Sample. METHODS We analyzed survey-weighted National Inpatient Sample data (2015-2020) to include emergent admissions of aged adults (50+ years) with a primary diagnosis of lower extremity ALI undergoing index procedures within 2 days of hospitalization. We excluded hospitalizations with concurrent trauma or dissection diagnoses and index procedures using catheter-directed thrombolysis. Our primary outcome was composite in-hospital major amputation or death. Secondary outcomes included in-hospital major amputation, death, in-hospital reintervention (including angioplasty/stent, thrombolysis, PT, OT, or bypass), and extended length of stay (eLOS; defined as LOS >75th percentile). Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were generated by multivariable logistic regression, adjusting for demographics, frailty (Risk Analysis Index), secondary diagnoses including atrial fibrillation and peripheral artery disease, hospital characteristics, and index procedure data including the anatomic thrombectomy level and fasciotomy. A priori subgroup analyses were performed using interaction terms. RESULTS We included 23,795 survey-weighted ALI hospitalizations (mean age: 72.2 years, 50.4% female, 79.2% White, and 22.3% frail), with 7335 (30.8%) undergoing PT. Hospitalization characteristics for PT vs OT differed by atrial fibrillation (28.7% vs 36.5%, P < .0001), frequency of intervention at the femoropopliteal level (86.2% vs 88.8%, P = .009), and fasciotomy (4.8% vs 6.9%, P = .006). In total, 2530 (10.6%) underwent major amputation or died. Unadjusted (10.1% vs 10.9%, P = .43) and adjusted (aOR = 0.96 [95% CI, 0.77-1.20], P = .74) risk did not differ between the groups. PT was associated with increased odds of reintervention (aOR = 2.10 [95% CI, 1.72-2.56], P < .0001) when compared with OT, but this was not seen in the tibial subgroup (aOR = 1.31 [95% CI, 0.86-2.01], P = .21, Pinteraction < .0001). Further, 79.1% of PT hospitalizations undergoing reintervention were salvaged with endovascular therapy. Lastly, PT was associated with significantly decreased odds of eLOS (aOR = 0.80 [95% CI, 0.69-0.94], P = .005). CONCLUSIONS PT was associated with comparable in-hospital limb salvage and mortality rates compared with OT. Despite an increased risk of reintervention, most PT reinterventions avoided open surgery, and PT was associated with a decreased risk of eLOS. Thus, PT may be an appropriate alternative to OT in appropriately selected patients.
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Affiliation(s)
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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Cervin A. The Occluded Prosthetic Bypass Graft: What To Do? Eur J Vasc Endovasc Surg 2024; 67:797-798. [PMID: 37683999 DOI: 10.1016/j.ejvs.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Anne Cervin
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
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Qi Y, Wang J, Yuan D, Duan P, Hou L, Wang T. Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury. World J Emerg Surg 2024; 19:16. [PMID: 38678282 PMCID: PMC11055329 DOI: 10.1186/s13017-024-00544-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVE For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. METHODS The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. RESULTS A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%). CONCLUSION Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.
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Affiliation(s)
- Yuhan Qi
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiarong Wang
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
| | - Ding Yuan
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
| | - Pengchao Duan
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Hou
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tiehao Wang
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China.
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Crupi L, Ardizzone A, Calapai F, Scuderi SA, Benedetto F, Esposito E, Capra AP. The Impact of COVID-19 on Amputation and Mortality Rates in Patients with Acute Limb Ischemia: A Systematic Review and Meta-Analysis. Diseases 2024; 12:74. [PMID: 38667532 PMCID: PMC11048752 DOI: 10.3390/diseases12040074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
Since the inception of the SARS-CoV-2 pandemic, healthcare systems around the world observed an increased rate of Acute Limb Ischemia (ALI) in patients with a COVID-19 infection. Despite several pieces of evidence suggesting that COVID-19 infection may also worsen the prognosis associated with ALI, only a small number of published studies include a direct comparison regarding the outcomes of both COVID-19 and non-COVID-19 ALI patients. Based on the above, a systematic review and a meta-analysis of the literature were conducted, evaluating differences in the incidence of two major outcomes (amputation and mortality rate) between patients concurrently affected by COVID-19 and negative ALI subjects. PubMed (MEDLINE), Web of Science, and Embase (OVID) databases were scrutinized from January 2020 up to 31 December 2023, and 7906 total articles were recovered. In total, 11 studies (n: 15,803 subjects) were included in the systematic review, and 10 of them (15,305 patients) were also included in the meta-analysis. Across all the studies, COVID-19-positive ALI patients experienced worse outcomes (mortality rates ranging from 6.7% to 47.2%; amputation rates ranging from 7.0% to 39.1%) compared to non-infected ALI patients (mortality rates ranging from 3.1% to 16.7%; amputation rates ranging from 2.7% to 18%). Similarly, our meta-analysis shows that both the amputation rate (OR: 2.31; 95% CI: 1.68-3.17; p < 0.00001) and mortality (OR: 3.64; 95% CI: 3.02-4.39; p < 0.00001) is significantly higher in COVID-19 ALI patients compared to ALI patients.
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Affiliation(s)
- Lelio Crupi
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Alessio Ardizzone
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Fabrizio Calapai
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Sarah Adriana Scuderi
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, 98125 Messina, Italy;
| | - Emanuela Esposito
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Anna Paola Capra
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
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Earnshaw JJ, Björck M. Oxygen Supplementation in Acute Limb Ischaemia? Eur J Vasc Endovasc Surg 2024; 67:693. [PMID: 38056521 DOI: 10.1016/j.ejvs.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Affiliation(s)
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
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Vlastos D, Bown MJ, Ikonomidis I. The Dose Makes the Poison: the Case Against Routine Oxygen Supplementation in Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2024; 67:692-693. [PMID: 38056520 DOI: 10.1016/j.ejvs.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Dimitrios Vlastos
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK; 2nd Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
| | - Matthew J Bown
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ignatios Ikonomidis
- 2nd Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Erol ME, Civelek İ, Ozyalcin S, Beyazpınar DS, Kandemir O. Predicting Amputation Rates in Acute Limb Ischemia: Is the Neutrophil-Lymphocyte Ratio a Reliable Indicator? Cureus 2024; 16:e59253. [PMID: 38686104 PMCID: PMC11057397 DOI: 10.7759/cureus.59253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/02/2024] Open
Abstract
Objective This study aimed to investigate the causes of amputation and the associated biochemical parameters in patients with acute limb ischemia (ALI). Methods Patients who presented to our clinic with ALI between January 2012 and January 2022 were deemed eligible for participation. Patients who developed ALI owing to atherosclerosis or atrial fibrillation were included in the study. In contrast, patients who developed ALI owing to trauma, iatrogenic causes, or popliteal artery aneurysms were excluded. Patients' demographic data, biochemical parameters, and hemogram values at the time of admission were retrospectively analyzed. Results A total of 374 patients were included in the study. Of them, 57.82% (n = 218) were male and 42.18% (n= 156) were female. Amputation was required in 7.95% (n = 30) of the patients after presenting with ALI and receiving necessary surgical or medical intervention. Multivariate analysis revealed the symptom-to-door time to be the primary factor determining the need for amputation in patients. With each passing hour following the manifestation of symptoms, the risk of amputation increased by 1.3 times [odds ratio (OR): 1.289%, 95% confidence interval (CI): 1.079-1.540 p = 0.05]. The neutrophil-to-lymphocyte ratio (NLR) and other hematological parameters had no effect on amputation in both univariate and multivariate analyses (OR: 1.49%; 95% CI: 0.977-2.287 p = 0.512). Conclusions Based on our findings, the main factor affecting the need for amputation in ALI patients was the symptom-to-door time. Biochemical and hematological parameters had no effect on amputation in ALI.
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Affiliation(s)
- Mehmet Emir Erol
- Department of Cardiovascular Surgery, Ankara Etlik City Hospital, Ankara, TUR
| | - İsa Civelek
- Department of Cardiovascular Surgery, Ankara Etlik City Hospital, Ankara, TUR
| | - Sertan Ozyalcin
- Department of Cardiovascular Surgery, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ozer Kandemir
- Department of Cardiovascular Surgery, Ankara Etlik City Hospital, Ankara, TUR
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13
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Ripoll T, Fairag R, Bonomo I, Gastaud O, Psacharopulo D. Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach. Vasc Endovascular Surg 2024; 58:245-254. [PMID: 37823274 DOI: 10.1177/15385744231206834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.
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Affiliation(s)
- Thomas Ripoll
- Service de Chirurgie Vasculaire, Centre Hospitalier de Cannes, Cannes, France
- Service de Chirurgie Orthopédique, Centre Hospitalier de Cannes, Cannes, France
| | - Rayan Fairag
- Service de Chirurgie Orthopédique, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Iris Bonomo
- Service de Gynécologie, Institut Bergonié, Bordeaux, France
| | - Olivier Gastaud
- Service de Chirurgie Orthopédique, Centre Hospitalier de Cannes, Cannes, France
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14
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Espitia O, Del Giudice C, Hartung O, Herquelot E, Schmidt A, Sapoval M, Sobocinski J. Editor's Choice -- Survival, Limb Salvage, and Management of Patients with Lower Limb Acute Ischaemia: A French National Retrospective Observational Study. Eur J Vasc Endovasc Surg 2024; 67:631-642. [PMID: 37926151 DOI: 10.1016/j.ejvs.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The aim was to describe the baseline characteristics of French patients referred with acute limb ischaemia (ALI), and their clinical management and outcome (death, amputation). METHODS This retrospective observational cohort study used the National Health Data System. All adults hospitalised for ALI who underwent revascularisation with an endovascular or open surgical approach between 1 January 2015 and 31 December 2020 were included and followed up until death or the end of the study (31 December 2021). A one year look back period was used to capture patients' medical history. The risks of death, and major and minor amputations were described using Kaplan-Meier and Aalen-Johansen estimators. A Cox model was used to report the adjusted association between groups and risk of death and Fine-Gray models for the risk of amputations considering the competing risk of death. RESULTS Overall, 51 390 patients (median age 70 years, 69% male) were included and had a median follow up of 2.7 years: 39 411 (76.7%) were treated with an open approach and 11 979 (23.3%) with a percutaneous endovascular approach. The preferred approach for the revascularisation varied between French regions. The one year overall survival was 78.0% and 85.2% in the surgery and endovascular groups, respectively. The surgery group had a higher risk of death (hazard ratio [HR] 1.17, 95% CI 1.12 - 1.21), a higher risk of major amputation (sub-distribution HR 1.20, 95% CI 1.10 - 1.30) and lower risk of minor amputation (sub-distribution HR 0.66, 95% CI 0.60 - 0.71) than the endovascular group. Diabetes and dialysis increased the risk of major amputation by 52% and 78%, respectively. Subsequent ALI was the third most common cause of hospital re-admission within one year. CONCLUSION ALI remains a condition at high risk of death and amputation. Individual risk factors and ALI severity need to be considered to choose between approaches. Continued prevention efforts, improved management, and access to the most suitable approach are necessary.
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Affiliation(s)
- Olivier Espitia
- Nantes Université, CHU Nantes, Department of internal and vascular medicine, F-44000 Nantes, France.
| | | | - Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France
| | | | | | - Marc Sapoval
- Radiologie interventionnelle, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jonathan Sobocinski
- Chirurgie vasculaire et endovasculaire, Centre Hospitalier Universitaire de Lille, Lille, France
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15
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Simons J, Mees B, MacLaren G, Fraser JF, Zaaqoq AM, Cho SM, Patel BM, Brodie D, Bělohlávek J, Belliato M, Jung JS, Salazar L, Meani P, Mariani S, Di Mauro M, Yannopoulos D, Broman LM, Chen YS, Riera J, van Mook WN, Lorusso R. Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation. Perfusion 2024; 39:23S-38S. [PMID: 38651584 DOI: 10.1177/02676591241236650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.
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Affiliation(s)
- Jorik Simons
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Barend Mees
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bhavesh M Patel
- Department of Critical Care, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
| | - Mirko Belliato
- SC AR 2 Anestesia e Terapia Intensiva Cardiotoracica, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea
| | - Leonardo Salazar
- Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Paolo Meani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- S. Gerardo Hospital is the hospital of the departmen, Monza, Italy
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Lars Mikael Broman
- Department of Pediatric Perioperative Medicine and Intensive Care, ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jordi Riera
- Department de Medicina Intensiva, Vall d'Hebron Institut de Recerca, SODIR, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Walther Nka van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Acosta S, Kulezic A, Zarrouk M, Gottsäter A. Management of Acute Lower Limb Ischemia Without Surgical Revascularization - A Population-Based Study. Vasc Endovascular Surg 2024; 58:316-325. [PMID: 37941090 PMCID: PMC10880409 DOI: 10.1177/15385744231215552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To evaluate outcomes of management without surgical revascularization in patients with acute lower limb ischemia (ALI) in a population-based setting. DESIGN Retrospective observational population-based study. MATERIALS Patients from Malmö, Sweden, hospitalized for ALI between 2015 and 2018. METHODS In-hospital, surgical, radiological, and autopsy registries were scrutinized for descriptive data on ALI patients managed by endovascular and open vascular surgery, conservative vascular therapy, primary major amputation, and palliative care. RESULTS Among 161 patients, 73 (45.3%) did not undergo any operative revascularization. Conservative vascular therapy, primary amputation, and palliative care were conducted in 25 (15.5%), 26 (16.1%), and 22 (13.7%) patients, respectively. Conservatively treated patients had Rutherford class ≥ IIb ischemia and embolic occlusion in 33% and 68% of cases, respectively. Their median C-reactive protein level at admission was 7 mg/L (interquartile range 2 - 31 mg/L). Among conservatively treated patients, anticoagulation therapy in half to full dose was given to 22 (88%) patients for six weeks or longer, and analgesics in low or moderate doses were given to twelve (48%) patients at discharge. The major amputation rate at 1 year was 8% among conservatively treated patients, and four patients with foot embolization had not undergone amputation at 1 year. CONCLUSION Patients selected for initial conservative therapy of ALI with anticoagulation alone may have a good outcome, even when admitted with Rutherford class IIb ischemia. A low C-reactive protein level at admission seems to be a favorable marker when choosing conservative therapy. A prospective, preferably multicenter, study with a predefined protocol in these conservatively treated patients is warranted to better define the dose and length of anticoagulation therapy.
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Affiliation(s)
- Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Andrea Kulezic
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Moncef Zarrouk
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Acute and Internal Medicine, Skåne University Hospital, Malmö, Sweden
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Behrendt CA, Lareyre F. There are Many Ways to Navigate in a Fog: Management of Acute Limb Threat in France. Eur J Vasc Endovasc Surg 2024; 67:643. [PMID: 37923188 DOI: 10.1016/j.ejvs.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Medical School Brandenburg, Theodor Fontane, Neuruppin, Germany.
| | - Fabien Lareyre
- Department of Vascular Surgery, Hospital of Antibes Juan-les-Pins, France; Université Côte d'Azur, INSERM U1065, C3M, Nice, France
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18
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Kikuchi S, Ohira S, Doita T, Kamada K, Kuriyama N, Tamaru Y, Tatsukawa T, Yoshida Y, Uchida D, Azuma N. Super-Elderly Case of Acute Lower Limb Ischemia Treated with Indigo Aspiration System in Japan. Ann Vasc Dis 2024; 17:63-68. [PMID: 38628935 PMCID: PMC11018105 DOI: 10.3400/avd.cr.23-00095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 04/19/2024] Open
Abstract
The Indigo Aspiration System (Penumbra Ltd., Alameda, CA, USA), a catheter-based device intended for the endovascular removal of clots from peripheral arteries and veins, was launched in Japan to treat acute limb ischemia after the cessation of urokinase sales. The initial application of this system in Japan was on a 96-year-old male patient. He was diagnosed with acute lower limb ischemia, which was caused by an embolism from a left common iliac artery aneurysm. The treatment significantly enhanced the perfusion to his left foot. This case report elaborates on the patient's treatment experience and discusses the indications for using the device.
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Affiliation(s)
- Shinsuke Kikuchi
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Seima Ohira
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tsutomu Doita
- Department of Cardiovascular Surgery, Osaka University, Suita, Osaka, Japan
| | - Keisuke Kamada
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Naoya Kuriyama
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuya Tamaru
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takamitsu Tatsukawa
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuri Yoshida
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Daiki Uchida
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Maldonado TS, Powell A, Wendorff H, Rowse J, Nagarsheth KH, Dexter DJ, Dietzek AM, Muck PE, Arko FR, Chung J. Safety and efficacy of mechanical aspiration thrombectomy for patients with acute lower extremity ischemia. J Vasc Surg 2024; 79:584-592.e5. [PMID: 37931885 DOI: 10.1016/j.jvs.2023.10.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Acute limb ischemia (ALI) is associated with high rates of amputation and consequent morbidity and mortality. The objective of this study is to report on the safety and efficacy of aspiration thrombectomy using the Indigo Aspiration System in patients with lower extremity (LE) ALI. METHODS The STRIDE study was an international, multicenter, prospective, study that enrolled 119 participants presenting with LE-ALI. Patients were treated firstline with mechanical thrombectomy using the Indigo Aspiration System, before stenting or angioplasty, or other therapies as determined by treating physician. The primary end point was target limb salvage at 30 days after the procedure. Secondary end points within 30 days included technical success, defined as core laboratory-adjudicated Thrombolysis in Myocardial Infarction (TIMI) 2/3 flow rate immediately after the procedure, changes in modified Society for Vascular Surgery runoff score, improvement of Rutherford classification compared with before the procedure, patency, rate of device-related serious adverse events, and major periprocedural bleeding. Secondary end points that will be evaluated at 12 months include target limb salvage and mortality. RESULTS Of the 119 participants enrolled at 16 sites, the mean age was 66.3 years (46.2% female). At baseline (n = 119), ischemic severity was classified as Rutherford I in 10.9%, Rutherford IIa in 54.6%, and Rutherford IIb in 34.5%. The mean target thrombus length was 125.7 ± 124.7 mm. Before the procedure, 93.0% (of patients 107/115) had no flow (TIMI 0) through the target lesion. The target limb salvage rate at 30 days was 98.2% (109/111). The rate of periprocedural major bleed was 4.2% (5/119) and device-related serious adverse events was 0.8% (1/119). Restoration of flow (TIMI 2/3) was achieved in 96.3% of patients (105/109) immediately after the procedure. The median improvement in the modified Society for Vascular Surgery runoff score (before vs after the procedure) was 6.0 (interquartile range, 0.0-11.0). Rutherford classifications also improved after discharge in 86.5% of patients (83/96), as compared with preprocedural scores. Patency at 30 days was achieved in 89.4% of patients (101/113). CONCLUSIONS In the STRIDE (A Study of Patients with Lower Extremity Acute Limb Ischemia to Remove Thrombus with the Indigo Aspiration System) study, aspiration thrombectomy with the Indigo System provided a safe and effective endovascular treatment for patients with LE-ALI, resulting in a high rate (98.2%) of successful limb salvage at 30 days, with few periprocedural complications.
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Affiliation(s)
| | | | | | - Jarrad Rowse
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - Frank R Arko
- Sanger Heart and Vascular Institute, Charlotte, NC
| | - Jayer Chung
- Division of Vascular Surgery & Endovascular Therapy, Baylor College of Medicine, Houston, TX
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20
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Karonen E, Eek F, Butt T, Acosta S. Sex differences in outcomes after revascularization for acute lower limb ischemia: Propensity score adjusted analysis. World J Surg 2024; 48:746-755. [PMID: 38501573 DOI: 10.1002/wjs.12058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/13/2023] [Indexed: 03/20/2024]
Abstract
BACKGROUND Previous reports have suggested higher rates of mortality and amputation for female patients in acute lower limb ischemia (ALI). The aims of the present study were to investigate if there is a difference in mortality, amputation, and fasciotomy between the sexes. METHODS A retrospective cohort study of consecutive patients undergoing index revascularization for ALI between 2001 and 2018 was conducted. A propensity score was created through a logistic regression with female/male sex as an outcome. Cox regression analyses for 90-day and 1-year mortality, combining major amputation/mortality, and logistic regression for major bleeding and fasciotomy, were performed. All analyses were performed with and without adjusting for propensity score. RESULTS A total of 709 patients were included in the study of which 45.9% were women. Mean age was 72.1 years. Females were older and had higher rates of atrial fibrillation, embolic disease, and lower estimated glomerular filtration rate, while men more often had anemia and chronic peripheral arterial disease. Mortality at 1 year was 21.2% for women and 14.7% for men. The adjusted hazard ratio for 1-year mortality was 0.99 (95% CI 0.67-1.46). Fasciotomy was performed in 7.1% of female and 12.8% of male patients; the adjusted odds ratio was 0.52 (95% CI 0.29-0.91). CONCLUSION Sex was not found to be an independent risk factor for mortality or combined major amputation/mortality after revascularization for acute lower limb ischemia, whereas women had lower odds of undergoing fasciotomy. Whether women are underdiagnosed or do not develop acute compartment syndrome in the lower leg as often as men should be evaluated prospectively.
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Affiliation(s)
- Emil Karonen
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Frida Eek
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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21
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Casian D, Predenciuc A, Culiuc V. Clinical value of foot thermometry in patients with acute limb ischemia. Vascular 2024:17085381241237494. [PMID: 38426388 DOI: 10.1177/17085381241237494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE We hypothesized that the severity of foot poikilothermy can be used for better differentiation of grades of acute limb ischemia. Thus, the study aim was evaluation of the value of non-contact foot thermometry, performed using a low-cost infrared medical thermometer, as an adjunct for clinical diagnosis of immediately threatened acute limb ischemia. METHODS It was a single-center observational prospective study performed over 3 years. Patients with acute limb ischemia of lower limbs grade I-IIB Rutherford treated with urgent revascularization were included. Grade of ischemia was determined independently by two experienced vascular surgeons. Thermometry of the ischemic foot was performed using a medical digital infrared non-contact thermometer (CK-T1501, Cooligg, China) with measuring accuracy of ±0.2°C. Temperature was measured in three points: the dorsal surface of the foot, plantar surface of the foot (both in the metatarsal region), and forehead. The maximal temperature gradient between patient's forehead and foot (∆Tmax F-F) was calculated. Measurements were repeated 6-12 h after revascularization. RESULTS A total of 147 patients were included. Only 3 (2%) patients presented rest pain without sensory loss and motor deficit, while the majority were diagnosed with mild (63/147, 42.8%) or moderate (27/147, 18.3%) motor deficit. The temperature of the ischemic foot varied from 20 to 36.1°C, while median value of the temperature was 26.7 [24.5-29.9] °C on the dorsal surface and 26.8 [24.5-29.6] °C on the plantar surface of the foot (p = 0.85). Patients with Grade IIB ischemia had significantly lower dorsal foot temperature, plantar foot temperature, and larger ∆Tmax F-F than the patients with grades I-IIA: 25.1 [23.9-26.8] °C versus 29.9 [27.6-30.8] °C; 25.2 [23.8-27.5] °C versus 29.6 [28-31.1] °C; and 11.6 [9.7-12.8] °C versus 7.2 [6-9] °C (p < 0.0001). Areas under ROC curve for diagnosis of Grade IIB ischemia were similar for dorsal foot temperature (0.82), plantar temperature (0.81), and ∆Tmax F-F (0.82). The best cutoff value by Youden was ≥9.5°C for ∆Tmax F-F, ≤26.8°C for dorsal, and ≤27.7°C for plantar temperature. Criterion ∆Tmax F-F offered the highest specificity of 86% (95%CI 74.2-93.7) and positive predictive value of 89.2% (95%CI 79.5-93.2), while plantar temperature offered sensitivity of 82.5% (95%CI 70.1-91.3) and negative predictive value of 69.1% (95%CI 57.6-83.2). In multivariate analysis including age, gender, and etiology of arterial occlusion, the criterion ∆Tmax F-F of ≥9.5°C was a unique variable significantly associated with risk of amputation (adjusted OR 2.6, 95%CI 1.2-5.9, p = 0.01). CONCLUSION Current study demonstrated that patients with immediately threatening ALI have significantly lower foot temperature than those with viable and marginally threatened limbs. Severe foot poikilothermy at admission is associated with poor outcomes of revascularization, mostly with limb loss.
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Affiliation(s)
- Dumitru Casian
- Vascular Surgery Clinic, Department of General Surgery nr, 3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
- Division of Vascular Surgery, Institute of Emergency Medicine, Chisinau, Moldova
| | - Alexandru Predenciuc
- Vascular Surgery Clinic, Department of General Surgery nr, 3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
- Division of Vascular Surgery, Institute of Emergency Medicine, Chisinau, Moldova
| | - Vasile Culiuc
- Vascular Surgery Clinic, Department of General Surgery nr, 3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
- Division of Vascular Surgery, Institute of Emergency Medicine, Chisinau, Moldova
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Soares RDA, Campos ABC, Portela MVV, Brienze CS, Brancher GQB, Sacilotto R. Pharmacomechanical thrombectomy with Angiojet in acute arterial occlusions: A prospective study among the results and outcomes. Vascular 2024:17085381241237559. [PMID: 38429875 DOI: 10.1177/17085381241237559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
OBJECTIVE The main objective of this present paper was to evaluate the results and outcomes of patients with acute limb ischemia (ALI) submitted to pharmacomechanical thrombectomy (PMT) endovascular surgery with Angiojet, regarding the number of cycles/pumps. METHODS Prospective, consecutive cohort study of ALI patients submitted to PMT endovascular intervention subdivided into two groups according to the number of cycles in the Angiojet technique: Group 1 higher than 150 cycles/second and Group 2 lesser than 150 cycles/second (cycles/s). RESULTS Overall, 92 patients with ALI submitted to PMT were evaluated. Two groups of patients were identified: Group 1 higher than 150 cycles/s with 60 patients and Group 2 lesser than 150 cycles/s with 32 patients. The overall mortality rate (OMR) was 15.1% (13 patients) in total cohort within the first 30 days. Group 1 had a higher OMR than Group 2 (16.1% vs 9.3%, p = 0.007). There were 4 cases of hematuria (4.3%), all of them in Group 1. We have performed a Kaplan-Meier regarding limb salvage rates: Group 1 had 85% and Group 2 had 95.7% at 1057 days. P = 0.081. Among the factors evaluated, the following were related to overall mortality rate: PMT with higher >150 cycles/s (HR = 7.17, p = 0.007, CI: 1.38-8.89), COVID-19 infection (HR = 2.75, p = 0.010, CI = 1.73-5.97), and post-operative acute kidney injury (HR = 2.97, p < 0.001, CI = 1.32-8.13). Among the factors evaluated, the following was related to limb loss: post-operative acute kidney injury (HR = 4.41, p = 0.036, CI: 1.771-7.132), probably because patients experiencing limb loss have a higher incidence of acute renal insufficiency due to higher circulating myoglobin higher hemolysis from the increased Angiojet cycles inducing rhabdomyolysis. CONCLUSION PMT with Angiojet is a safe and effective therapy in patients with ALI. However, patients receiving greater than 150 cycles/s were noted to have higher rates of acute kidney injury and mortality. This is likely reflective of increased thrombus burden and higher rates of hemolysis. Acute kidney injury, greater than 150 cycles/s, and COVID-19 infection were the variables with the strongest association to perioperative mortality.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Ana Beatriz Campelo Campos
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Matheus Veras Viana Portela
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Carolina Sabadoto Brienze
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | | | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
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Tan M, Takahara M, Haraguchi T, Uchida D, Dannoura Y, Shibata T, Iwata S, Azuma N. One-Year Clinical Outcomes and Prognostic Factors Following Revascularization in Patients With Acute Limb Ischemia - Results From the RESCUE ALI Study. Circ J 2024; 88:331-338. [PMID: 37544740 DOI: 10.1253/circj.cj-23-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Acute limb ischemia (ALI) is a limb- and life-threatening condition and urgent treatment including revascularization should be offered to patients unless the limb is irreversibly ischemic. The aim of this study was to investigate 1-year clinical outcomes and prognostic factors following revascularization in patients with ALI.Methods and Results: A retrospective, multicenter, nonrandomized study examined 185 consecutive patients with ALI treated by surgical revascularization (SR), endovascular revascularization (ER), or hybrid revascularization (HR) in 6 Japanese medical centers from January 2015 to August 2021. The 1-year amputation-free survival (AFS) rate was estimated to be 69.2% (95% confidence interval [CI], 62.8-76.2%). There were no significant differences among SR, ER, and HR regarding both technical success and perioperative complications. Multivariate analysis revealed that Rutherford category IIb and III ischemia (hazard ratio [HR]: 1.86; 95% CI: 1.06-3.25), supra- to infrapopliteal lesion (HR: 2.06; 95% CI: 1.08-3.95), and technical failure (HR: 2.58; 95% CI: 1.49-4.46) were independent risk factors for 1-year AFS. CONCLUSIONS Rutherford category IIb and III ischemia, supra- to infrapopliteal lesions, and technical failures were identified as independent risk factors for 1-year AFS. Furthermore, patients with multiple risk factors had a lower AFS rate.
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Affiliation(s)
- Michinao Tan
- Cardiovascular Center Tokeidai Memorial Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine
| | | | - Daiki Uchida
- Department of Vascular Surgery, Asahikawa Medical University
| | - Yutaka Dannoura
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University
| | - Shuko Iwata
- Cardiovascular Center Tokeidai Memorial Hospital
- Department of Cardiovascular Medicine, Nayoro City General Hospital
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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Thaarup M, Jacobsen S, Nielsen PB, Nicolajsen CW, Eldrup N, Petersen CN, Behrendt CA, Dahl M, Højen AA, Søgaard M. Adherence and Persistence to Antiplatelet Therapy in Lower Extremity Peripheral Arterial Disease: A Danish Population Based Cohort Study. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00161-8. [PMID: 38341174 DOI: 10.1016/j.ejvs.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/25/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Adherence to antiplatelet therapy is recommended but unexplored in patients with symptomatic lower extremity peripheral arterial disease (PAD). Therefore, this study aimed to determine adherence and persistence to antiplatelet therapy in patients with PAD, defined as intermittent claudication and chronic limb threatening ischaemia. DESIGN Population based nationwide cohort study. METHODS This study included all Danish citizens aged ≥ 40 years with a first inpatient or outpatient diagnosis of symptomatic PAD between 2010 - 2017, and who had at least one prescription claim for aspirin and/or clopidogrel within 90 days after diagnosis. Adherence was determined by the proportion of days covered (PDC) during the first year after diagnosis. Persistence was defined as no treatment gap ≥ 30 days between prescription renewals over three year follow up. RESULTS A total of 39 687 patients were eligible for inclusion, of whom 23 279 (58.7%) claimed a prescription for aspirin and/or clopidogrel within 90 days of diagnosis. Among these, 12 898 (55.4%) were prevalent users, while the remainder comprised new users who initiated the therapy after the index PAD diagnosis. The mean PDC was 74.5% (SD 35.0%) for prevalent users and 60.5% (SD 30.5%) for new users. Adherence increased with age and number of concomitant drugs. The overall one year cumulative incidence treatment discontinuation was 13.0% (95% CI 12.5 - 13.4%) overall, 17.2% (CI 16.6 - 17.9%) for prevalent users, and 7.9% (CI 7.4 - 8.4%) for new users. At three year follow up, the cumulative incidence of discontinuation was 31.5% (CI 30.9 - 32.2%) overall, 44.6% (CI 43.7 - 45.4%) for prevalent users, and 14.6% (CI 13.9 - 15.3) for new users. CONCLUSION Less than 60% of patients with newly diagnosed symptomatic PAD claimed a prescription for antiplatelet therapy within 90 days of diagnosis, and both adherence and persistence were moderate during the first year after diagnosis. These findings underscore the importance of efforts to improve the initiation and continuation of antiplatelet therapy in patients with PAD.
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Affiliation(s)
- Maja Thaarup
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Sara Jacobsen
- Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Denmark
| | | | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Marie Dahl
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Research Unit of Cardiac, Thoracic, and Vascular Surgery, Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Anette Arbjerg Højen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Denmark
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Denmark.
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Péčová M, Benko J, Péč MJ, Bolek T, Hurtová T, Sokol J, Staško J, Samoš M, Mokáň M. Unilateral upper and lower limb ischemia mimics stroke: a case report. J Med Case Rep 2024; 18:66. [PMID: 38308343 PMCID: PMC10837969 DOI: 10.1186/s13256-023-04240-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/01/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Although stroke and acute limb ischemia seem easily distinguishable by anamnesis and physical examination, symptoms may overlap and sometimes mislead the examiner. Such a situation can arise in the occurrence of unilateral neurological symptoms affecting the upper and lower limbs at the same time. As timely diagnosis and a correct therapeutic intervention are crucial to prevent irreversible damage in both diseases, knowledge of the possibility of one disease mimicking the other is essential. We present a unique case of acute unilateral upper and lower limb ischemia mimicking an acute stroke. CASE PRESENTATION A 69-year-old Caucasian patient with known atherosclerotic risk factors was admitted to the emergency department with a suspected stroke with unilateral paresthesia. After a comprehensive examination of the patient with the need for repeated reevaluation and a negative brain computed tomography scan, acute left-sided upper and lower limb ischemia was eventually diagnosed. The patient underwent surgical revascularization of the upper and lower limbs with a satisfactory result and was discharged from the hospital after a few days. CONCLUSION It is of utmost importance to always stay alert for stroke mimics, as overlooking can lead to severe complications and delay adequate therapy. Our case shows that persistent diagnostic effort leads to successful treatment of the patient even on rare occasions, as is the acute unilateral upper and lower limb ischemia.
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Affiliation(s)
- Monika Péčová
- Oncology Centre, Teaching Hospital Martin, Kollárova 2, 036 01, Martin, Slovakia
- Department of Hematology and Transfusion Medicine, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Jakub Benko
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia.
- Department of Cardiology, Teaching Hospital Nitra, 950 01, Nitra, Slovakia.
| | - Martin Jozef Péč
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia.
| | - Tomáš Bolek
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Tatiana Hurtová
- Department of Infectology and Travel Medicine and Department of Dermatovenerology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Juraj Sokol
- Department of Hematology and Transfusion Medicine, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Ján Staško
- Department of Hematology and Transfusion Medicine, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Matej Samoš
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
- Division of Acute and Interventional Cardiology, Department of Cardiology and Angiology II., Mid-Slovakian Institute of Heart and Vessel Diseases (SÚSCCH, a.s.), 974 01, Banská Bystrica, Slovakia
| | - Marián Mokáň
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
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Kulezic A, Acosta S, Ekberg O, Lehti L. Extravascular incidental findings in computed tomography angiography are associated with lower amputation-free survival in patients with acute lower limb ischaemia. Vascular 2024; 32:126-131. [PMID: 36268567 DOI: 10.1177/17085381221135272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Emergency computed tomography angiography (CTA) is the most important imaging modality to visualize arterial occlusions in patients with acute lower limb ischaemia (ALI). Extravascular incidental findings (EVIFs) have received less attention. PURPOSE The aims of this study were to evaluate the incidence of EVIFs of immediate clinical relevance in patients with ALI undergoing CTA and evaluate the association between EVIFs and emergency revascularization and amputation-free survival at 1 year. METHODS Retrospective cohort study. Emergency CTA in patients with ALI between 2015 and 2018 were independently scrutinized by two senior radiologists. EVIFs were classified into immediate (category I), potential (category II) or no clinical relevance (category III). Multi-variable binary logistic regression analysis was expressed in Odds ratios (OR) with 95% confidence intervals (CI). RESULTS The intra-class correlation (ICC) coefficient for EVIF category I between the raters was 0.94 (95% CI 0.92-0.96). Among 118 patients with ALI, 78 patients underwent emergency revascularization. Forty-six EVIFs (34 patients) were category I, of which 63% were found in the chest, including pleural effusion (n = 12), pneumonia (n = 8) and cardiac thrombus (n = 4). Ascites (n = 4) and cancer disease (n = 4) were other category I findings. Category I EVIFs were associated with reduced rate of emergency revascularization (OR 0.26, 95% CI 0.10-0.66) and increased rate of combined major amputation/mortality at 1 year (OR 2.9, 95% CI 1.1-8.2) in adjusted analysis. CONCLUSION It is important to evaluate EVIFs in emergency CTA in patients with ALI since these findings are both common and associated with reduced emergency revascularization and amputation-free survival at 1 year.
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Affiliation(s)
- Andrea Kulezic
- Department of Clinical Sciences, Malmö Lund University, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Malmö Lund University, Malmö, Sweden
- Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Olle Ekberg
- Division of Medical Radiology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Leena Lehti
- Department of Clinical Sciences, Malmö Lund University, Malmö, Sweden
- Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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Hayashi M, Obara H, Matsuda S, Homma K, Sasaki J, Matsubara K, Higuchi M, Sano M, Masugi Y, Kitagawa Y. Protective Effects of Hydrogen Gas Inhalation for Hindlimb Ischaemia-Reperfusion Injury in a Mouse Model. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00108-4. [PMID: 38301869 DOI: 10.1016/j.ejvs.2024.01.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Ischaemia-reperfusion (I/R) injury is a severe post-operative complication that triggers an inflammatory response and causes severe damage. Hydrogen gas has anti-oxidant and anti-apoptotic properties and has been shown to be safe in humans. The study aimed to investigate whether hydrogen gas protects against skeletal muscle I/R injury. METHODS Experimental basic research using mice. A total of 160 eight to 10 week old albino laboratory bred strain of house mice (25.8 ± 0.68 g) were used in this study. The mice were cable tied to the hindlimb under anaesthesia and then placed in an anaesthesia box filled with air and 2% isoflurane (control group); 80 mice were additionally subjected to 1.3% hydrogen gas in this mix (hydrogen group). After two hours, the cable ties were removed to initiate reperfusion, and hydrogen inhalation lasted for six hours in the hydrogen group. After six hours, the mice were taken out of the box and kept in cages under standard conditions until time for observation at 16 different time points after reperfusion: zero, two, four, six, eight, and 10 hours and one, two, three, four, five, six, seven, 14, 21, and 28 days. Five mice were sacrificed using excess anaesthesia at each time point, and the bilateral hindlimb tissues were harvested. The inflammatory effects of the I/R injury were assessed by evaluating serum interleukin-6 concentrations using enzyme linked immunosorbent assay, as well as histological and immunohistochemical analyses. Untreated mice with I/R injury were used as controls. RESULTS Hydrogen gas showed protective effects associated with a reduction in inflammatory cell infiltration (neutrophils, macrophages, and lymphocytes), a reduced area of damaged muscle, maintenance of normal muscle cells, and replacement of damaged muscle cells with neoplastic myocytes. CONCLUSION Inhalation of hydrogen gas had a protective effect against hindlimb I/R injury in mice, in part by reducing inflammatory cell infiltration and in part by preserving normal muscle cells.
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Affiliation(s)
- Masanori Hayashi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Japan.
| | - Sachiko Matsuda
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Makoto Higuchi
- Ogino Memorial Laboratory, Nihon Kohden Corporation, Tokorozawa, Japan
| | - Motoaki Sano
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
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Rockhold M, Kunkel L, Lacoste JL, Szymanski T, Rothenberg P, Zimmerman P, Minc S. Comparison of direct oral anticoagulants and warfarin in chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)00256-8. [PMID: 38278371 DOI: 10.1016/j.jvs.2024.01.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE The role of direct oral anticoagulants (DOACs) in chronic limb-threatening ischemia after revascularization is unknown. Current evidence-based guidelines do not provide clear guidance on the role of anticoagulation or the selection of anticoagulant. Current practice is highly varied and based on provider and patient preference. The purpose of this study was to measure the impact of different anticoagulants on the incidence of major adverse limb events (MALEs) after revascularization for chronic limb-threatening ischemia, major adverse cardiovascular events (MACEs), all-cause mortality, and hospitalization for major bleeding events. METHODS This was a single-center, observational, retrospective cohort study. Subjects were eligible if they were 18 years or older; underwent endovascular or open revascularization for chronic limb-threatening ischemia, rest pain, or tissue loss; and were subsequently prescribed apixaban, rivaroxaban, or warfarin. The primary end point was the incidence of MALEs, including above-ankle amputation or major index-limb reintervention, within 1 year of index event. Secondary end points included the rate of all-cause mortality, MACEs, and incidence of International Society on Thrombosis and Haemostasis (ISTH) major bleeding. RESULTS From January 1, 2017, to September 20, 2022, 141 patients met the inclusion and exclusion criteria and were reviewed. The median age was 67 years, with 92 patients prescribed apixaban or rivaroxaban and 49 patients prescribed warfarin. Of these, 42 patients were prescribed triple antithrombotic therapy, 88 dual antithrombotic therapy, and 13 anticoagulant monotherapy. The primary outcome of 1-year MALEs occurred in 36.7% of the warfarin group and 33.7% of the DOAC group (relative risk [RR], 1.09; 95% CI, 0.53-2.25; P = .72). Secondary outcomes of 1-year MACEs (10.2% vs 4.3%; RR, 2.35; 95% CI, 0.60-9.18; P = .18) and 1-year all-cause mortality (26.5% vs 16.3%; RR, 1.63; 95% CI, 0.70-3.78; P = .15) did not differ between the groups. The secondary safety outcome of 1-year ISTH major bleeding occurred in 16.3% of the warfarin group and 4.3% of the DOAC group (RR, 3.76; 95% CI, 1.07-13.19; P = .015). CONCLUSIONS In patients with chronic limb-threatening ischemia who were revascularized and prescribed anticoagulation with apixaban, rivaroxaban, or warfarin on discharge, no difference in MALEs, MACEs, or all-cause mortality was found. However, 1-year admissions for ISTH major bleeding were significantly higher among patients prescribed warfarin. A randomized trial may confirm these findings.
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Affiliation(s)
- Matthew Rockhold
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV.
| | - Lauren Kunkel
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV
| | - Jordan L Lacoste
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV
| | - Thomas Szymanski
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV
| | - Paul Rothenberg
- West Virginia University Medicine, Department of General Surgery, Morgantown, WV
| | - Pamela Zimmerman
- West Virginia University Medicine, Department of Vascular Surgery, Morgantown, WV
| | - Samantha Minc
- West Virginia University Medicine, Department of Vascular Surgery, Morgantown, WV
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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Simonte G, Isernia G, Pecoraro F, Antonello M, Guzzardi G, Dinoto E, Feriani G, Migliara B. Rotational Mechanical Thrombectomy to Treat Iliac Limb Occlusion after Endovascular Aortic Aneurysm Repair: The Rotational Mechanical Thrombectomy Italian Study. J Vasc Interv Radiol 2024; 35:25-31. [PMID: 37776993 DOI: 10.1016/j.jvir.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/23/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023] Open
Abstract
PURPOSE To assess the safety and effectiveness of a rotational mechanical atherothrombectomy device in patients with symptomatic iliac limb occlusion after abdominal endovascular aneurysm repair (EVAR). MATERIALS AND METHODS A retrospective analysis was conducted on patients who underwent rotational mechanical thrombectomy using the Rotarex S device for symptomatic acute, subacute, or chronic graft limb thrombosis at 5 vascular centers between 2017 and 2021. This study comprised 23 male patients with a mean age of 74.5 years (SD ± 7.2) at the time of the procedure. The clinical presentation of the patients varied, with 1 patient experiencing acute limb ischemia and 11 patients (47.8%) experiencing disabling intermittent claudication. The remaining patients developed chronic limb-threatening ischemia after iliac limb occlusion. Early outcomes included technical success, postprocedural complications, and periprocedural mortality. Follow-up evaluations encompassed primary patency, patient survival, freedom from reintervention, and the need for surgical conversion. RESULTS Technical success was achieved in all cases, with no occurrences of distal embolization during or after the procedure, and no periprocedural deaths were reported. Endograft relining was performed in 82.6% of patients to establish a new, nonthrombogenic surface within the graft. Over a median follow-up period of 8 months (interquartile range, 3-16 months), 2 patients experienced iliac limb reocclusion. No deaths or other reinterventions occurred during the observational follow-up period. CONCLUSIONS Rotational mechanical thrombectomy for iliac limb occlusion after EVAR appears to be both safe and effective. This technique may uncover intraluminal defects contributing to graft occlusion and enable their resolution within the same procedure.
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Affiliation(s)
- Gioele Simonte
- Vascular and Endovascular Surgery Unit, S. Maria Della Misericordia University Hospital, Perugia, Italy.
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, S. Maria Della Misericordia University Hospital, Perugia, Italy
| | - Felice Pecoraro
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Palermo, Italy; Vascular Surgery Unit, Azienda Ospedaliera Universitaria Policlinico 'P. Giaccone, Palermo, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Unit, University of Padua, Padova, Italy
| | - Giuseppe Guzzardi
- Interventional Radiology Unit, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Ettore Dinoto
- Vascular Surgery Unit, Azienda Ospedaliera Universitaria Policlinico 'P. Giaccone, Palermo, Italy
| | - Giovanni Feriani
- Vascular and Endovascular Surgery Unit, Pederzoli Hospital, Peschiera del Garda (VR), Italy
| | - Bruno Migliara
- Vascular and Endovascular Surgery Unit, Pederzoli Hospital, Peschiera del Garda (VR), Italy
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Casajuana Urgell E, Calsina Juscafresa L, Mascaró Oliver M, Abadal Jou M, Clarà Velasco A. Acute limb ischemia in nonagenarians: Characteristics and factors related to outcomes in a single-center consecutive series. World J Surg 2024; 48:240-249. [PMID: 38686799 DOI: 10.1002/wjs.12021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/31/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. MATERIALS AND METHODS Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. RESULTS A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. CONCLUSION Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.
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Affiliation(s)
- Eduard Casajuana Urgell
- Department of Vascular Surgery, Hospital del Mar, Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Calsina Juscafresa
- Department of Vascular Surgery, Hospital del Mar, Barcelona, Spain
- Department of Life and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Mar Abadal Jou
- Department of Vascular Surgery, Hospital del Mar, Barcelona, Spain
| | - Albert Clarà Velasco
- Department of Vascular Surgery, Hospital del Mar, Barcelona, Spain
- Department of Life and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Cardiovascular, IMIM-Parc de Salut Mar, Barcelona, Spain
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Billones AR, Imperial CR, Gutierrez-Cayetano M. Embolism from a left ventricular myxoma presenting with acute limb ischaemia. BMJ Case Rep 2023; 16:e254934. [PMID: 38050388 PMCID: PMC10693896 DOI: 10.1136/bcr-2023-254934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
Acute limb ischaemia (ALI) secondary to cardiac myxoma is uncommon. Embolic myxoma should be considered a differential diagnosis in young patients with ALI who do not have apparent cardiovascular risk factors. A multidisciplinary approach and comprehensive care can improve outcomes and optimise the collaborative treatment of ALI. Early referral to a hospital that can provide specialised treatment for ALI helps prevent significant tissue loss and surgical complications, such as amputation.A man in his 20s presented with bilateral ALI of both lower extremities, and an arterial duplex scan revealed a thrombus occluding all arterial segments of the bilateral lower extremities. An intracardiac mass adherent to the apical and anterior interventricular septum on two-dimensional echocardiography suggested a complex myxoma. The patient was diagnosed with ALI Rutherford category III, and bilateral hip disarticulation was performed. The patient was discharged with an anticoagulant.
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Shu HT, Covarrubias O, Shah MM, Muquit ST, Yang VB, Zhao X, Kagabo W, Shou BL, Kalra A, Whitman G, Kim BS, Cho SM, LaPorte DM, Shafiq B. What Factors Are Associated With Arterial Line-Related Limb Ischemia in Patients on Extracorporeal Membrane Oxygenation? A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:2489-2498. [PMID: 37735020 DOI: 10.1053/j.jvca.2023.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/27/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES The primary purpose of this study was to identify factors associated with the development of arterial line-related limb ischemia in patients on extracorporeal membrane oxygenation (ECMO). The authors also sought to characterize and report the outcomes of patients who developed arterial line-related limb ischemia. DESIGN Retrospective cohort study. SETTING A single academic tertiary referral ECMO center. PARTICIPANTS Consecutive patients who were treated with ECMO over 6 years. INTERVENTIONS Use of arterial line. MEASUREMENTS AND MAIN RESULTS A total of 278 consecutive ECMO patients were included, with 19 (7%) patients developing arterial line-related limb ischemia during the ECMO run. Postcannulation Sequential Organ Failure Assessment (SOFA) (adjusted odds ratio [aOR] 1.20, 95% CI 1.08-1.32), Acute Physiology and Chronic Health Evaluation-II (aOR 0.84, 95% CI 0.74-0.95), and adjusted Vasopressor Dose Equivalence (aOR 1.03, 95% CI 1.01-1.05) scores were independently associated with the development of arterial line-associated limb ischemia. A SOFA score of ≥17 at the time of ECMO cannulation had an 80% sensitivity and 87% specificity for predicting arterial line-related limb ischemia. CONCLUSIONS Arterial line-related limb ischemia is much more common in ECMO patients than in the typical intensive care unit setting. The SOFA score may be useful in identifying which patients may be at risk for arterial line-related limb ischemia. As this was a single-center retrospective study, these results are inherently exploratory, and prospective multicenter studies are necessary to validate these results.
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Affiliation(s)
- Henry T Shu
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Oscar Covarrubias
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Manuj M Shah
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Siam T Muquit
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor B Yang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiyu Zhao
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Whitney Kagabo
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dawn M LaPorte
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Simonte G, Fino G, Casali F, Parlani G, Lenti M, Isernia G. Effectiveness of the Rotarex Excisional Atherectomy System in Both Subacute and Chronic Aortoiliac Endograft Thrombosis: An Innovative Option for the Modern Endovascular Surgeon Toolkit. J Endovasc Ther 2023; 30:957-963. [PMID: 35735194 DOI: 10.1177/15266028221105177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report a successful revascularization case using the Rotarex™S atherothrombectomy system in a recent iliac limb thrombosis, and chronic hypogastric stent obstruction after previous aortoiliac aneurysm endovascular repair (EVAR). CASE REPORT A 72-year-old patient was treated for recent right iliac limb thrombosis and left iliac branch chronic hypogastric stent occlusion, 5 years after EVAR. A total endovascular approach, using both upper extremity and femoral vascular access, was settled with 2 Rotarex™S (6Fr and 10Fr) devices. The Rotarex™S catheters removed most of the intraluminal material, allowing additional endografts and bare metal stents to be deployed to support a new healthy lumen surface. CONCLUSION The total endovascular approach provided by the Rotarex™S device appears to be safe and effective in treating aortoiliac endografts occlusions, both in subacute and chronic phases. Larger studies could highlight differences and eventual advantages compared with more traditional solutions.
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Affiliation(s)
- Gioele Simonte
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
- Unit of Vascular Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Gianluigi Fino
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Francesco Casali
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Gianbattista Parlani
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Potpara T, Angiolillo DJ, Bikdeli B, Capodanno D, Cole O, Yataco AC, Dan GA, Harrison S, Iaccarino JM, Moores LK, Ntaios G, Lip GYH. Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report. Chest 2023; 164:1531-1550. [PMID: 37392958 DOI: 10.1016/j.chest.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Evidence increasingly shows that the risk of thrombotic complications in COVID-19 is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of VTE. However, an urgent need exists for practical guidance on the management of arterial thrombosis and thromboembolism in this setting. RESEARCH QUESTION What is the current available evidence informing the prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19? STUDY DESIGN AND METHODS A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that address urgent clinical questions regarding prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19. Using MEDLINE via PubMed, a literature search was conducted and references were screened for inclusion. Data from included studies were summarized and reviewed by the panel. Consensus for the direction and strength of recommendations was achieved using a modified Delphi survey. RESULTS The review and analysis of the literature based on 11 PICO questions resulted in 11 recommendations. Overall, a low quality of evidence specific to the population with COVID-19 was found. Consequently, many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19. INTERPRETATION The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis according to recommendations predating the COVID-19 pandemic. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse. More high-quality evidence is needed to inform management strategies in these patients.
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Affiliation(s)
- Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia; Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia.
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT; Cardiovascular Research Foundation, New York, NY
| | - Davide Capodanno
- Azienda Ospedalielo-Universitaria Policlinico "G- Rodolico-San Marco", University of Catania, Catania, Italy
| | - Oana Cole
- Liverpool Heart and Chest Hospital, Liverpool, England
| | - Angel Coz Yataco
- Departments of Critical Care and of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gheorghe-Andrei Dan
- "Carol Davila" University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England
| | - Jonathan M Iaccarino
- The Pulmonary Center, Boston University School of Medicine, Boston, MA; American College of Chest Physicians, Glenview, IL
| | - Lisa K Moores
- The Uniformed Services University of the Health Sciences, Bethesda, MD
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Wafi A, Ribeiro L, Kolli V, Azhar B, Budge J, Loftus IM, Holt PJE. Predicting Prosthetic Mobility at Discharge From Rehabilitation Following Major Amputation in Vascular Surgery. Eur J Vasc Endovasc Surg 2023; 66:832-839. [PMID: 37734438 DOI: 10.1016/j.ejvs.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 07/30/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE This study aimed to construct a decision aid to estimate the likelihood of independence with a prosthesis following rehabilitation for limb loss secondary to advanced ischaemia (acute or chronic limb threatening ischaemia) or diabetic foot disease (DFD). A secondary aim was to determine whether prosthetic independence is a surrogate marker of long term survival. METHODS A retrospective cohort study of a prospectively maintained database of unilateral amputations due to ischaemia or DFD entering rehabilitation between 2007 and 2020 was performed. Predictors of independent prosthetic mobility (IPM) were used in construction of the IPM prediction model, which underwent bootstrap internal and criterion validation through correlation with predictors of other measures of function: Timed Up and Go (TUG) and two minute walk test. Kaplan-Meier and Cox regression analyses were performed to address the secondary aim. RESULTS Of the 771 patients included, only 49.9% of amputees achieved IPM. Independent negative predictors of IPM were age > 75 years, female sex, higher amputation level, active malignancy, cerebrovascular disease, end stage renal disease, and cognitive impairment. The model yielded high discrimination (C statistic 0.778), and internal validation was demonstrated with bootstrapping (C statistic 0.778), confirming no over optimism. There was a strong correlation between IPM, TUG, and two minute distance and their predictors, confirming strong criterion validity. The IPM group had a median survival of 93.7 (80.7, 105) months, whereas the non-IPM group fared worse with a median survival of 56.6 (48.5, 66.7) months (p < .001). CONCLUSION An internally validated decision aid for estimating the likelihood of independence with a prosthesis after major amputation was constructed. A strong association between female sex and poorer prosthetic mobility was observed. Prosthetic function was shown to be a surrogate marker of long term survival. Future research will involve external validation studies to confirm the generalisability of the decision aid in clinical practice.
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Affiliation(s)
- Arsalan Wafi
- St George's Vascular Institute, St George's University Hospital, London, UK.
| | - Luis Ribeiro
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Vijay Kolli
- Douglas Bader Rehabilitation Unit, Queen Mary's Hospital, London, UK
| | - Bilal Azhar
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - James Budge
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Ian M Loftus
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Peter J E Holt
- St George's Vascular Institute, St George's University Hospital, London, UK
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Liesker DJ, Gareb B, Speijers MJ, VAN DER Vorst JR, Salemans PB, Tutein Nolthenius RP, Zeebregts CJ, Saleem BR. Outcomes of Omniflow® II prosthesis used for revascularization in the femoral tract both in infected and non-infected setting. J Cardiovasc Surg (Torino) 2023; 64:634-644. [PMID: 37306682 DOI: 10.23736/s0021-9509.23.12692-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Evidence regarding the outcomes of Omniflow® II prosthesis in peripheral arterial revascularization at different anatomical sites and for different indications is scarce. Therefore, the aim of this study was to evaluate the outcomes of the Omniflow® II used at various positions within the femoral tract both in infected and non-infected setting. METHODS Patients who underwent reconstructive lower leg vascular surgery with implantation of an Omniflow® II from 2014 until 2021 at five medical centers were retrospectively included (N.=142). Patients were subdivided into the following categories: femoro-femoral crossover (N.=19), femoral interposition (N.=18), femoro-popliteal (above-the-knee [N.=25; AK] or below-the-knee [N.=47; BK]), and femoro-crural bypass grafts (N.=33). Primary outcome was primary patency and secondary outcomes included primary assisted patency, secondary patency, major amputation, vascular graft infection, and mortality. Outcomes were compared according to different subgroups and the surgical setting (infected versus non-infected). RESULTS The median follow-up was 35.0 (17.5-54.3) months. Three years primary patency of 58% was observed for femoro-femoral crossover bypass, 75% for femoral interposition graft, 44% for femoro-popliteal above-the-knee bypass, 42% for femoro-popliteal below-the-knee bypass, and 27% in the femoro-crural position (P=0.006). Freedom from major amputation at three years were 84% for femoro-femoral crossover bypass, 88% for femoral interposition bypass, 90% for femoro-popliteal AK bypass, 83% for femoro-popliteal BK bypass, and 50% for femoro-crural bypass (P<0.001). CONCLUSIONS This study demonstrates the safety and feasibility of the use of Omniflow® II for femoro-femoral crossover-, femoral interposition-, and femoro-popliteal (AK and BK) bypass. Omniflow® II seems to be less suitable for femoro-crural bypass with a significantly lower patency compared to other positions.
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Affiliation(s)
- David J Liesker
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands -
| | - Barzi Gareb
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Maarten J Speijers
- Division of Vascular Surgery, Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - Joost R VAN DER Vorst
- Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Pieter B Salemans
- Division of Vascular Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Rudolf P Tutein Nolthenius
- Division of Vascular Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ben R Saleem
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Konstantinou N, Argyriou A, Dammer F, Bisdas T, Chlouverakis G, Torsello G, Tsilimparis N, Stavroulakis K. Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia. J Endovasc Ther 2023:15266028231210232. [PMID: 38009372 DOI: 10.1177/15266028231210232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
PURPOSE To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). METHODS This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). CONCLUSION Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. CLINICAL IMPACT Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.
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Affiliation(s)
| | - Angeliki Argyriou
- Department of Vascular Surgery, Marien Hospital Herne, Herne, Germany
| | - Felicitas Dammer
- Department of Vascular Surgery, University Hospital LMU Munich, Munich, Germany
| | - Theodosios Bisdas
- Department of Vascular and Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Gregory Chlouverakis
- Biostatistics Laboratory, Department of Social Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Muenster, Germany
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Murray G, Nagarsheth K. Farther Geographic Distance and Lower Socioeconomic Status should not Preclude Transfer of Acute Limb Ischemia to Tertiary Care Centers. Am Surg 2023; 89:4990-4991. [PMID: 36541164 DOI: 10.1177/00031348221146951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Affiliation(s)
- Gillian Murray
- University of Maryland School of Medicine, Baltimore, MD, USA
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Pomatto S, Faggioli G, Pini R, Ficarelli I, Pini A, Angherà C, Rocchi C, Caputo S, Vacirca A, Ruotolo C, Gargiulo M. Limb salvage and survival after urgent surgical treatment of popliteal artery aneurysm. World J Emerg Surg 2023; 18:49. [PMID: 37838652 PMCID: PMC10576300 DOI: 10.1186/s13017-023-00514-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/21/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Popliteal artery aneurysms (PAAs) need urgent treatment in case of acute thrombosis, distal embolization, or rupture. Few data are available in the literature about the treatment results in these scenarios. The aim of the present study was to evaluate an 11-year multicenter experience in the urgent treatment of PAAs. METHODS All symptomatic PAAs surgically treated in two vascular centers between 2010 and 2021 were retrospectively analyzed. In the postoperative period periodical clinical and Duplex-Ultrasound evaluation were performed. The evaluated endpoint was the outcome of urgent PAAs treatment according to their clinical presentation. Statistical analysis was performed by Kaplan-Meier log-rank evaluation and multivariable Cox regression tests. RESULTS Sixty-six PAAs needed an urgent repair. Twelve (18%) patients had a PAA rupture and 54 (82%) had an acute limb ischemia (ALI) due to either distal embolization or acute thrombosis. Patients with ALI underwent bypass surgery in 51 (95%) cases, which was associated with preoperative thrombolysis in 18 (31%) cases. A primary major amputation was performed in 3 (5%) cases. The mean follow-up was 52 ± 21 months with an overall 5-year limb salvage of 83 ± 6%. Limb salvage was influenced only by the number of patent tibial arteries (pTA) [5-years limb salvage 0%, 86 ± 10%, 92 ± 8% and 100% in case of 0, 1, 2 or 3 pTA, respectively (P = .001)]. An independent association of number of pTA and limb loss was found [hazard ratio (HR): 0.14 (95% confidence interval (CI) 0.03-0.6), P = .001]. Overall 5-year survival was 71 ± 7%. Ruptured PAAs were associated with lower 5-year survival compared with the ALI group (48 ± 2% vs. 79 ± 7%, P = .001). The number of pTA (33 ± 20%, 65 ± 10%, 84 ± 10% and 80 ± 10% for 0, 1, 2 and 3 pTA, respectively, P = .001) and the thrombolysis (94 ± 6% vs. 62 ± 10%, P = .03) were associated with higher survival in patients with ALI. There was an independent association of number of pTA and long-term survival [HR 0.15 (95% CI 0.03-0.8), P = .03]. CONCLUSIONS PAA rupture is the cause of urgent PAA treatment in almost one fifth of cases, and it is associated with lower long-term survival. ALI can benefit from thrombolysis, and long-term limb salvage and survival are associated with the number of pTA.
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Affiliation(s)
- Sara Pomatto
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Ilaria Ficarelli
- Division of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131, Naples, Italy
| | - Alessia Pini
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Cecilia Angherà
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Cristina Rocchi
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Stefania Caputo
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
| | - Carlo Ruotolo
- Division of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131, Naples, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna "Alma Mater Studiorum" - DIMEC, Policlinico S. Orsola, Via Giuseppe Massarenti 9, 40138, Bologna, Italy
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
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Kohlman-Trigoboff D. Updates and Advances in Cardiovascular Nursing: Peripheral Arterial Disease. Nurs Clin North Am 2023; 58:337-356. [PMID: 37536785 DOI: 10.1016/j.cnur.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
This article focuses on peripheral arterial disease (PAD) of the lower extremities. There is a higher incidence of myocardial infarction, stroke, and cardiovascular death, resulting in higher rates of all-cause mortality compared with patients without PAD. Thus, the presence of PAD is a marker for systemic atherosclerotic disease and can lead to the early detection and treatment of coronary artery disease or cerebrovascular disease. This article reviews the latest information about the prevalence, symptoms, classification, diagnosis, and treatment of PAD. Monitoring and detection of PAD are also discussed, including implications for nursing care.
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Vinojan S, Gooneratne TD, Twine CP, Hinchliffe RJ. Editor's Choice - Quality Assessment of European Society for Vascular Surgery Clinical Practice Guidelines. Eur J Vasc Endovasc Surg 2023; 66:304-312. [PMID: 37330203 DOI: 10.1016/j.ejvs.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE An increasing number of clinical practice guidelines (CPGs) have emerged over recent years. To have clinical utility, they need to be rigorously developed and scientifically robust. Instruments have been developed to assess the quality of clinical guideline development and reporting. The aim of this study was to evaluate CPGs from the European Society for Vascular Surgery (ESVS) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. METHODS CPGs published by the ESVS during the period January 2011 to January 2023 were included. Two independent reviewers assessed the guidelines after receiving training in the use and application of the AGREE II instrument. Inter-reviewer reliability was assessed with the intraclass correlation coefficient. Maximum scaled scores were 100. Statistical analysis was performed using SPSS Statistics v.26. RESULTS Sixteen guidelines were included in the study. Good inter-reviewer score reliability was found on statistical analysis (> 0.9). The mean ± standard deviation domain scores were 68.1 ± 20.3% for scope and purpose, 57.1 ± 21.1% for stakeholder involvement, 67.8 ± 19.5% for rigour of development, 78.1 ± 20.6% for clarity of presentation, 50.3 ± 15.4% for applicability, 77.6 ± 17.6% for editorial independence, and 69.8 ± 20.1% for overall quality. Stakeholder involvement and applicability have improved in quality over time but are still the lowest scoring domains. CONCLUSION Most ESVS clinical guidelines are of high quality and reporting. There is scope for improvement, specifically by addressing the domains of stakeholder involvement and clinical applicability.
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Affiliation(s)
- Satchithanantham Vinojan
- Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka; University of Bristol, Bristol, UK.
| | - Thushan D Gooneratne
- University of Bristol, Bristol, UK; Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Robert J Hinchliffe
- University of Bristol, Bristol, UK; Department of Vascular Surgery, North Bristol NHS Trust, UK
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Abstract
Management of acute limb ischemia is complex and time sensitive, and delays in diagnosis and treatment may lead to irreversible tissue damage. Current data challenge the commonly accepted 6-hour ischemic threshold for acute limb ischemia, although variations in practice remain. Patients with chronic peripheral artery disease may tolerate longer ischemia time due to presence of collateral circulation. Here the authors discuss the presentation, workup, management, and postoperative care of patients with acute limb ischemia, with a focus on how management is altered depending on the duration and degree of ischemia.
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Affiliation(s)
- Alexis L Lauria
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street - Halsted 668, Baltimore, MD 21287, USA.
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Stoklasa K, Sieber S, Naher S, Bohmann B, Kuehnl A, Stadlbauer T, Wendorff H, Biro G, Kallmayer MA, Knappich C, Busch A, Eckstein HH. Patients with Acute Limb Ischemia Might Benefit from Endovascular Therapy-A 17-Year Retrospective Single-Center Series of 985 Patients. J Clin Med 2023; 12:5462. [PMID: 37685530 PMCID: PMC10487798 DOI: 10.3390/jcm12175462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
Acute lower limb ischemia (ALI) is a common vascular emergency, requiring urgent revascularization by open or endovascular means. The aim of this retrospective study was to evaluate patient demographics, treatment and periprocedural variables affecting the outcome in ALI patients in a consecutive cohort in a tertiary referral center. Primary outcome events (POE) were 30-day (safety) and 180-day (efficacy) combined mortality and major amputation rates, respectively. Secondary outcomes were perioperative medical and surgical leg-related complications and the 5-year combined mortality and major amputation rate. Statistical analysis used descriptive and uni- and multivariable Cox regression analysis. In 985 patients (71 ± 9 years, 56% men) from 2004 to 2020, the 30-day and 180-day combined mortality and major amputation rates were 15% and 27%. Upon multivariable analysis, older age (30 d: aHR 1.17; 180 d: 1.27) and advanced Rutherford ischemia stage significantly worsened the safety and efficacy POE (30 d: TASC IIa aHR 3.29, TASC IIb aHR 3.93, TASC III aHR 7.79; 180 d: TASC IIa aHR 1.97, TASC IIb aHR 2.43, TASC III aHR 4.2), while endovascular treatment was associated with significant improved POE after 30 days (aHR 0.35) and 180 days (aHR 0.39), respectively. Looking at five consecutive patient quintiles, a significant increase in endovascular procedures especially in the last quintile could be observed (17.5% to 39.5%, p < 0.001). Simultaneously, the re-occlusion rate as well as the number of patients with any previous revascularization increased. In conclusion, despite a slightly increasing early re-occlusion rate, endovascular treatment might, if possible, be favorable in ALI treatment.
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Affiliation(s)
- Kerstin Stoklasa
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
- Department of Vascular Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Sabine Sieber
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Thomas Stadlbauer
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
- Department of Vascular Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Heiko Wendorff
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Gabor Biro
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Michael A. Kallmayer
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Albert Busch
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University Dresden, 01307 Dresden, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
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Linnemann B, Espinola-Klein C. [Thromboembolic disease - the angiologist's point of view]. Dtsch Med Wochenschr 2023; 148:890-898. [PMID: 37493950 DOI: 10.1055/a-1825-7033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Thrombosis and embolism are among the most common causes of death worldwide and, in addition to venous thromboembolism with the two main manifestations of deep venous thrombosis and pulmonary embolism, also include arterial thrombotic disease such as myocardial infarction, stroke and systemic arterial embolism. It is often the interaction of several predisposing factors that leads to the formation of an intravascular thrombus. Changes in the vascular wall, the blood flow and the composition of the blood (Virchow's triad) play a decisive role in both the arterial and venous vascular systems. The management of thromboembolic diseases requires a dedicated clarification of the cause and classification of the disease process in order to minimize the risk of recurrence and embolic complications through differentiated antithrombotic therapy. For this purpose, a risk-benefit analysis based on the individual case and regular reassessment are of particular importance. In this article, the pathophysiological concepts of venous and arterial thrombosis and the main therapeutic implications resulting from this are reviewed.
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Spath P, Pasqui E, Angiletta D, Spinazzola A, Chegai F, Isernia G, Lepidi S, Silingardi R, de Donato G, Gargiulo M. Penumbra Indigo Percutaneous Aspiration Thrombectomy System in the treatment of Aortic Endograft Iliac Limb Occlusion: Results from an Italian Multicentre Registry. Eur J Vasc Endovasc Surg 2023; 66:77-84. [PMID: 37084878 DOI: 10.1016/j.ejvs.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/12/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE This study aimed to evaluate the safety and effectiveness of the Penumbra Indigo percutaneous aspiration thrombectomy (PAT) system in the clinical presentation of iliac limb occlusion (ILO) after endovascular aortic repair (EVAR). METHODS A retrospective, observational, multicentre study conducted in eight Italian vascular centres. Consecutive patients presenting with ILO after EVAR were eligible. To assess vessel revascularisation, Thrombo-aspiration In Peripheral Ischaemia (TIPI) classification (score 0-3) was used at presentation (t1), after PAT (t2), and after adjunctive procedures (t3). Successful revascularisation was considered TIPI 2-3 (near complete or complete). Primary intra-operative outcomes were technical success (TS) of Indigo PAT and combined TS of PAT associated with adjunctive procedures when needed. Primary follow up outcomes were safety and effectiveness at one, six, and 12 months. RESULTS From September 2019 to December 2021, there were 48 ILO and 17 patients (35%) [median age 75 years, IQR 71, 83 years; male, 14 (82%); urgent, 8 (47%)] were treated and enrolled. The median time after primary EVAR was 24 months (IQR 0, 42 months). The median clot age from ILO diagnosis to PAT was three days (IQR 1, 12 days). Ten patients (59%) presented with limb threatening ischaemia. At t1, TIPI 0 and 1 was present in 13 (76%) and four (24%) cases, respectively. At t2, primary TS (TIPI 2-3) was achieved in 14 cases (82%) after Indigo PAT (p < .001). Fifteen patients (88%) required adjunctive procedures (14 re-linings, one surgical patch angioplasty). At t3, combined TS was achieved in 16 cases (94%). Intra-operative complication included one (6%) distal embolisation, treated successfully. The 30 day mortality was one case (6%) due to pneumonia. At one, six, and 12 months, clinical success was 100% without ILO recurrence. The median follow up was 23 months (IQR 11, 41 months): at 18 months, survival and freedom from re-intervention were 91 ± 8% and 90 ± 9%, respectively. CONCLUSION This study reports for the first time the efficacy and safety of Penumbra Indigo PAT for ILO after EVAR, with promising technical and clinical success up to one year.
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Affiliation(s)
- Paolo Spath
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy.
| | - Edoardo Pasqui
- Vascular Surgery, University of Siena, DSMCN, Siena, Italy
| | | | - Angelo Spinazzola
- Interventional Radiology, Unit of Radiology, ASST-Crema, Crema, Italy
| | - Fabrizio Chegai
- Vascular and Interventional Radiology, Unit of Radiology, Hospital Viterbo, Viterbo, Italy
| | - Giacomo Isernia
- Department of Vascular and Endovascular Surgery, University of Perugia, Perugia, Italy
| | - Sandro Lepidi
- Department of Vascular Surgery, University Hospital of Trieste, Trieste, Italy
| | - Roberto Silingardi
- Department Vascular Surgery of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
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Ferrer C, Cannizzaro GA, Borlizzi A, Caruso C, Giudice R. Acute ischemia of the upper and lower limbs: Tailoring the treatment to the underlying etiology. Semin Vasc Surg 2023; 36:211-223. [PMID: 37330235 DOI: 10.1053/j.semvascsurg.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 06/19/2023]
Abstract
Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or sudden decrease in limb perfusion producing new or worsening symptoms and signs, often threatening limb viability. ALI is commonly related to an acute arterial occlusion. Rarely, extensive venous occlusion can lead to upper and lower extremities ischemia (ie, phlegmasia). The incidence of acute peripheral arterial occlusion causing ALI is approximately 1.5 cases per 10,000 people per year. The clinical presentation depends on the etiology and whether the patient has underlying peripheral artery disease. Except for traumas, the most common etiologies are embolic or thrombotic events. Peripheral embolism, likely related to embolic heart disease, is the most common cause of acute upper extremity ischemia. However, an acute thrombotic event may occur in native arteries, at the site of a pre-existing atherosclerotic plaque, or as a failure of previous vascular interventions. The presence of an aneurysm may predispose to ALI for both embolic and thrombotic mechanisms. Immediate diagnosis, accurate assessment of limb viability, and prompt intervention, when needed, play important roles in salvaging the affected limb and preventing major amputation. Severity of symptoms is usually dependent on the amount of surrounding arterial collateralization, which may often reflect a pre-existing chronic vascular disease. For this reason, early recognition of the underlying etiology is crucial for choice of best management and definitely for treatment success. Any error in the initial evaluation may negatively affect the functional prognosis of the limb and endanger the patient's life. The aim of this article was to discuss diagnosis, etiology, pathophysiology, and treatment of patients with acute ischemia of the upper and lower limbs.
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Affiliation(s)
- Ciro Ferrer
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy.
| | | | - Adelaide Borlizzi
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Cataldo Caruso
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Rocco Giudice
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
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Enea I, Martelli E. Focus on the Prevention of Acute Limb Ischemia: Centrality of the General Practitioner from the Point of View of the Internist. J Clin Med 2023; 12:jcm12113652. [PMID: 37297848 DOI: 10.3390/jcm12113652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
The thrombotic mechanism, being common to peripheral arterial disease (PAD), acute myocardial infarction (AMI), and stroke, is responsible for the highest number of deaths in the western world. However, while much has been done for the prevention, early diagnosis, therapy of AMI and stroke, the same cannot be said for PAD, which is a negative prognostic indicator for cardiovascular death. Acute limb ischemia (ALI) and chronic limb ischemia (CLI) are the most severe manifestations of PAD. They both are defined by the presence of PAD, rest pain, gangrene, or ulceration and we consider ALI if symptoms last less than 2 weeks and CLI if they last more than 2 weeks. The most frequent causes are certainly atherosclerotic and embolic mechanisms and, to a lesser extent, traumatic or surgical mechanisms. From a pathophysiological point of view, atherosclerotic, thromboembolic, inflammatory mechanisms are implicated. ALI is a medical emergency that puts both limb and the patient's life at risk. In patients over age 80 undergoing surgery, mortality remains high reaching approximately 40% as well as amputation approximately 11%. The purpose of this paper is to summarize the scientific evidence on the possibilities of primary and secondary prevention of ALI and to raise awareness among doctors involved in the management of ALI, in particular by describing the central role of the general practitioner.
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Affiliation(s)
- Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, 81100 Caserta, Italy
| | - Eugenio Martelli
- Division of Vascular Surgery, Department of Cardiovascular Science, S. Anna and S. Sebastiano Hospital, Campania, 81100 Caserta, Italy
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Science, 00131 Rome, Italy
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Shi T, Zhang Y, Shen C, Fang J. A single-centre protocol using low-dose urokinase for catheter-directed thrombolysis in the treatment of acute lower limb ischaemia. Vascular 2023:17085381231174922. [PMID: 37139993 DOI: 10.1177/17085381231174922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Catheter-directed thrombolysis is one of the main treatments for acute limb ischaemia. Urokinase is still a widely used thrombolytic drug in some regions. However, there needs to be a clear consensus on the protocol of continuous catheter-directed thrombolysis using urokinase for acute lower limb ischaemia. METHODS A single-centre protocol of continuous catheter-directed thrombolysis with low-dose urokinase (20,000 IU/hour) lasting 48-72 h for acute lower limb ischaemia was proposed based on our previous experiences. A retrospective study from June 2016 to December 2020 was conducted to evaluate the efficacy and safety of this protocol. The target lesion revascularisation, amputation and death were also monitored during follow-up. The Kaplan-Meier estimator was used for the subgroup analysis, and univariate and multivariate Cox regression analysis was applied to identify risk factors for reinterventions and death. RESULTS 90 lower limbs were involved, including 51 Rutherford Grade I, 35 Grade IIa and four Grade IIb. During a 60.8-h thrombolysis, 86 cases (95.5%) were considered effective according to the angiogram. No major bleeding complication occurred during thrombolysis, and one amputation occurred after. Freedom from target lesion revascularisation, amputation and death were 75.6%, 94.4% and 91.1% during a mean 27.5-month follow-up, respectively. According to the Kaplan-Meier estimator, aortoiliac lesions had lower reintervention rates than femoropopliteal lesions (Log-rank p = 0.010), and cases without narrowing atheromatous plaque had a lower reintervention rate (Log-rank p = 0.049). Age was an independent risk factor for death (p = 0.038, hazard ratio 1.076, 95% confidence interval 1.004-1.153). CONCLUSIONS The single-centre protocol of catheter-directed thrombolysis we proposed for acute lower limb ischaemia was effective and safe. Strict blood pressure control during catheter-directed thrombolysis ensured safety. Aortoiliac lesions and cases without narrowing atheromatous plaque had lower reintervention rates during follow-up.
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Affiliation(s)
- Tao Shi
- Aortic and Vascular Surgery Centre, Fuwai Hospital, CAMS & PUMC, National Centre for Cardiovascular Diseases, China
| | - Yongbao Zhang
- Aortic and Vascular Surgery Centre, Fuwai Hospital, CAMS & PUMC, National Centre for Cardiovascular Diseases, China
| | - Chenyang Shen
- Aortic and Vascular Surgery Centre, Fuwai Hospital, CAMS & PUMC, National Centre for Cardiovascular Diseases, China
| | - Jie Fang
- Aortic and Vascular Surgery Centre, Fuwai Hospital, CAMS & PUMC, National Centre for Cardiovascular Diseases, China
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Natour AK, Shepard A, Rteil A, Kafri O, Lee A, Nypaver T, Weaver M, Dobesh K, Kabbani L. Necessity, Role, and Outcomes of Fasciotomy in Patients with Acute Limb Ischemia. Ann Vasc Surg 2023:S0890-5096(23)00244-3. [PMID: 37142120 DOI: 10.1016/j.avsg.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/05/2023] [Accepted: 04/20/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The incidence of compartment syndrome in patients with acute lower limb ischemia (ALLI) and the effects of fasciotomy on outcomes are largely undefined. This study aimed to define the incidence of compartment syndrome in patients with ALLI and to examine whether different fasciotomy strategies are associated with specific patient outcomes. METHODS A single center retrospective study of patients who had ALLI between April 2016 and October 2020 at a tertiary care center. Patients were categorized into groups as having received early and late therapeutic fasciotomy (TF), early prophylactic fasciotomy (PF), early exploratory fasciotomy, and no fasciotomy. Primary outcome was 30-day amputation rate. Secondary outcomes were 30-day and 1-year mortality, 1-year amputation rate, and length of stay. Groups were compared using descriptive statistics to assess the association of fasciotomy approach with outcomes. RESULTS During the study period, 266 patients were treated for ALLI, and 62 patients (23%) underwent 66 fasciotomies. A total of 41 TF, 23 PF, and 2 exploratory fasciotomies were done. There were 58 early fasciotomies performed (88% of 66 limbs): 33 (57%) early TF, 23 (40%) PF, and 2 (3%) exploratory. There were 8 patients who developed compartment syndrome after their revascularization operation and received delayed TF (12% of 66 limbs). The total number of TF was 41, which was 15% of all ALLI patients. The mean ± SD time to fasciotomy closure was 6.7 ± 5.7 days, which did not differ between PF and TF groups. Significantly more patients in the TF had an amputation at 30 days (11 [29%] vs 1 [5%]; P = 0.03) and at 1 year (6 [18%] vs 2 [9%]; P = 0.02) than those in the PF group. Length of stay was increased in both TF (16 days) and PF (19 days) patients compared to non-fasciotomy patients (10 days; P < 0.01) but did not differ between the 2 fasciotomy groups (P = 0.4). Thirty-day limb loss was highest in patients who underwent early TF (10/33, 33%), intermediate in those with delayed TF (1/8, 13%), and lowest in PF (1/23, 5%; P = 0.03). CONCLUSIONS Approximately 15% of patients with ALLI in our cohort required a TF for compartment syndrome. Close postoperative monitoring of ALLI patients who did not undergo early fasciotomy did detect delayed CS; however, this approach did not prevent limb loss. To optimize limb salvage, physicians treating patients with ALLI should be experienced in how to recognize and treat compartment syndrome.
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Affiliation(s)
| | | | - Ali Rteil
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Omar Kafri
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Alice Lee
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Timothy Nypaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Mitchell Weaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Kaitlyn Dobesh
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI.
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